Monday, March 04, 2013

OPM Final Rule Clarifies That Multi-State Plans Must Offer EHBs

On
Friday, the US Office of Personnel Management (OPM) published a final rule establishing
standards for the Multi-State Plan Program (MSPP) to promote competition in the
new health insurance marketplace, also known as the "exchanges,"
and ensure that consumers have more
high-quality, affordable insurance choices.

Under
the MSPP, OPM will enter into contracts with private health insurance issuers
to provide at least 2 Multi-State Plans (MSPs) in each state's exchange. MSPs
will be established in at least 31 exchanges this year, with coverage to be
extended to the exchanges/marketplaces in every state and the District of Columbia by
2017. At least 1 of these issuers must be a nonprofit entity. All state and
federal laws that apply to Qualified Health Plans (QHPs) also will apply to
MSPs.

Important
to physical therapists is the rule's clarification that MSPs must offer essential health benefits
(EHBs), and MSPP issuers must comply with state standards relating to
substitution of state benchmark benefits or standard benefit designs. As
reported in News Now on February 21, a final rule
on EHBs gives states authority to impose more stringent requirements on EHBs
substitution than the federal regulation, meaning that states can prohibit
substitution within EHB categories altogether. Additionally, MSPP plan issuers
are directed to follow state definitions of habilitative services and devices
where they exist. If a state has not defined the benefits, OPM will
determine them during negotiations with the MSPP issuer. To ensure network
adequacy (adequate number of provider and facility types), the rule
adopts an approach in which the MSPP will establish a uniform standard for
network adequacy using time and distance standards similar to the Centers for
Medicare and Medicaid Services' standards for Medicare Advantage plans and
Medicare Part D.

The
final rule also:

Reflects
OPM's commitment to collaborate with states to ensure that the MSPs are
competitively neutral in the marketplaces.

Sets
standards related to how OPM will coordinate with states and HHS to
approve rates, standards for rating, medical loss ratios, and an MSPP
issuer's participation in reinsurance, risk adjustment, and risk corridor
programs.

Establishes
how OPM will monitor contract performance for the MSPP, including ensuring
quality assurance, preventing fraud and abuse, and possible contract
compliance actions.

Creates
a process and standards for handling appeals for enrollees that are denied
claims for payment or service.

The
initial open enrollment period for MSPs, as with QHPs, begins October 1 for
coverage beginning January 1, 2014. Individuals and small businesses wishing to
enroll in MSPs will then be able to enroll through the marketplace in their
state. However, an MSP may not be available in every state until 2017.